Retained foreign bodies pose an ongoing threat to patient safety, with past studies suggesting intraoperative radiographic screening and counting as strategies to prevent their occurrence. This study examined the value of counting surgical instruments and quantified its accuracy in an effort not previously undertaken. Investigators discovered that the counting process prevented only half of retained items and count discrepancies led to increased surgical duration, an event associated with significant costs. The authors suggest that counting alone may not serve as the most effective prevention strategy and raise the role of technological innovations such as radiofrequency detection systems as a solution. An accompanying editorial reflects on the problem of retained foreign bodies in surgery, and a past AHRQ WebM&M commentary discusses an error and death due to a retained sponge.